Quality Metrics: What YOU Need to Know

Ann McQueenResearch and Policy Integration Manager

Aging and People with Disabilities

Oregon Department of Human Services

QMC Webinar – December 2019

1

Announcement – LiveWell Training

• Easy to understand quality improvement tools to track

these measures and others.

• FREE to all Oregon RCFs/ALFs – through the DHS

Quality Care Fund

• One-day basic trainings:

– Medford on Jan. 24

– Portland on Feb 4

– Salem on Feb. 7

• Sign up at: https://www.livewell-oregon.com/calendar

Objectives

• Review requirements for ALFs/RCFs to report Quality Metrics

• Discuss each of the five metrics in detail

• Discuss the online “Quality Metrics Application” (QMA) and reporting processes

• Discuss important dates and deadlines

• Address your questions along the way

• Help you feel more comfortable with the new reporting requirements!

Quality Metrics 101

• HB 3359 requires metrics be tracked and

reported by ALFs and RCFs

• Purpose: to improve quality of service and give

consumers and facilities a means of comparison

• Quality Measurement Council:

o Members appointed by the Governor

o Council develops program in collaboration

with DHS

o Eight council members, representing different

interests

Quality Metrics 101

1. Retention rate for direct care staff;

2. Compliance with staff training requirements;

3. Resident falls that result in physical injury;

4. Prescribed antipsychotic medication(s) for

nonstandard purposes;

5. Annual resident satisfaction survey results

conducted by an independent entity; and

6. A quality metric recommended by Quality

Measurement Council that measures the

resident experience.

Combined

into one

metric for

2020

Metric 1: Retention of Direct Care Staff

Why: Experienced staff provide better care for residents

When: Track from January 1, 2020 to December 31, 2020

What to track:

o Total number of direct care staff employed by facility for one calendar year or longer starting January 1, 2020

o Total number of direct care staff

employed at end of calendar year

(count on December 31, 2020)

This Photo by Unknown Author is

Metric 1: Retention of Direct Care Staff

Example:

• As of 12/31/2020, 24 direct care staff have been

continuously employed at the facility (no breaks in

employment) since 1/1/2020.

• As of 12/31/2020, the facility has a total of 39 direct care

staff working at the facility.

• The QMA will calculate: 24 ÷ 39 = 0.6153 =

61.5% staff retention rate for 2020.

Metric #2:Compliance with Staff Training

Why: Trained staff provide better care and have

higher job satisfaction

When: Track January 1, 2020 to December 31, 2020

How: Track the training of ALL employees

1) Determine if each employee is “direct care”

or “non-direct care” staff

2) Determine which staff have been

employed less than one year

Staff Training for Metric #2

o New Direct Care Staff - staff who provide direct resident care services and

have been employed at a facility for less than one year

o Experienced Direct Care Staff - staff who provide direct resident care services

and have been employed at a facility for one year or longer

o Non-Direct Care Staff - staff who do not provide direct resident care services,

such as housekeepers, management staff, maintenance, etc.

o New Direct Care Memory Care Staff - staff working in endorsed memory care

who provide direct resident care services and have been employed for less than

one year

o Experienced Direct Care Memory Care Staff - staff working in endorsed

memory care who provide direct care services and have been employed for one

year or longer

o Non-Direct Care Memory Care Staff - staff working in endorsed memory care communities who do not provide direct care services, such as housekeepers, maintenance, etc.

Metric #2 – Tracking Staff Training

What do you track?

For each group of employees, count:

1. Total number of staff who completed all required

trainings on time during 2020.

2. Total number of staff employed by the facility as of

December 31, 2020.

10

Optional Training Tracker for Metric #2

• Excel spreadsheet; formatted and locked for ease of use

• You choose whether or not to use the Training Tracker

• Tracker link available on CBC website in December 2019:

o Facilities can download and save to their computers

o Instructions attached to Tracker

o Technical assistance not available for Tracker

o Automatically calculates fields needed to enter into QMA

Optional Training Tracker for Metric #2

Metric #2: Staff Training Example

Type of staff

# of staff completing required training

on time # of staff total

Residential Care & Assisted Living Facilities

New Direct Care Staff 20 22

Experienced Direct Care Staff 36 40

Other Staff 10 10

Endorsed Memory Care Communities

NEW Memory Care Staff 5 6

Experienced Memory Care Staff 10 12

Other Memory Care Staff 4 5

As of 12/31: 85 95

QMA will calculate compliance rate: 85 ÷ 95 = 0.8947 = 89.47 = 89.5%

Metric #3: Falls with Injury

1) Total number of residents living in the facility on the last day of the month.

2) Total number of falls with injury during the month.

3) Number of residents with at least one fall with injury during the month.

4) Number of residents with more than one fall with injury during the month.

Why: Learn about causes and prevent as many serious falls as possible

When: Track July 1, 2020 through December 31, 2020

What to track each month:

Metric #3: Falls with Injury

Jan

Feb

Mar

Ap

r

May

Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Average Reported to Public

Total # of residents on last day of

month

40 42 44 41 43 43 40 38 39 42 44 42 41.5

Total number of falls with injury during

the past month

3 4 5 4 4 5 4 5 5 4 6 6 4.6

Number of residents

who fell with injury during

the past month

2 4 3 2 2 2 1 3 3 3 3 3 2.6

Number of residents

who fell with injury more than once during the

past month

1 0 1 2 1 1 1 2 2 2 2 2 1.4

The averages shown in the grayed column to the right will be reported to the public.

Each facility will have four averages reported for the calendar year.

Metric #4: Non-Standard Use

of Antipsychotics

Why track?

Concern that antipsychotic medications are being overused in facilities to calm undesirable behavioral and psychological symptoms of residents with dementia.

Goals:o Increase awarenesso Ensure person-centered assessments are usedo Encourage non-pharmacological treatments before

and with antipsychotics.

Metric #4: Non-Standard Use

of Antipsychotics

When: Track October 1, 2020 through October 31, 2020

How:

1. On 10/31/20, count the total number of residents in the facility.

2. Review the MAR and determine which residents were prescribed an antipsychotic on the FDA list ((found in Provider Instruction Guide) during the month.

3. Exclude any residents who have a diagnosis listed on the provided “Exclusions List” (found in Provider Instruction Guide).

4. Of the residents remaining after excluding those on the “Exclusions List,” determine how many of these residents had scheduled or PRN antipsychotics prescribed.

Metric #4: Non-Standard Use

of Antipsychotics

Example:

o On 10/31/20, there are 80 residents in the facility.

o After reviewing each MAR, it is determined 30 residents were prescribed an antipsychotic during October.

✓ See the Food and Drug Administration (FDA) List of antipsychotics – updated list will be provided with instructions – to ensure the medication is an antipsychotic.

Metric #4: Non-Standard Use

of Antipsychotics

Example (cont)

✓ Review the “Exclusions List:”

o 10 of the 30 residents prescribed an antipsychotic have an excluded diagnosis –these 10 residents are excluded from tracking

Exclusions List:

• Schizophrenia

• Schizoaffective Disorder

• Huntington’s Disease

• Tourette’s Syndrome

• Bipolar Disorder

• Depression

• Autistic Disorder

• Haldol prescribed for residents receiving hospice care

Metric #4: Non-Standard Use

of Antipsychotics

Example (cont.)

o Of the 20 residents remaining, determine whether they received a scheduled, non-standard or PRN prescription for antipsychotic medication:

o 15 had a scheduled non-standard prescription for antipsychotic medication, and

o 5 had a PRN prescription for antipsychotic medication.

Metric #4 - Antipsychotics

Example (cont.)

Enter three numbers into the QMA:

o 80 = Total number of residents in facility on Oct 31

o 15 = Number of residents prescribed a scheduled, non-standard antipsychotic medication during Oct

o 5 = Number of residents with PRN prescription for antipsychotic medication during Oct

21

Metric #4 - Antipsychotics

The QMA will perform the calculations:

• 15/80 = 0.1875 =

18.8% of residents had at least one prescription for a

scheduled antipsychotic for a non-standard purpose

during the month of October 2020.

• 5/80 = 0.0625 =

6.3% of residents had at least one PRN prescription

for an antipsychotic for a non-standard purpose

during the month of October 2020.

22

Metric #5: Resident

Experience/Satisfaction

The metric:

Results of annual resident satisfaction survey

conducted by an independent entity.

Important to remember:

• Independent entity must conduct survey

• Four required CoreQ questions

• Survey must be completed during 2020 with data

entered into QMA no later than January 31, 2021

Metric #5: Resident

Experience/Satisfaction

To find a CoreQ-approved vendor:

http://www.coreq.org/

• Click link at top of page for “Customer Satisfaction

Vendors”

• Facility needs to contract with a vendor

• Facility may hire the vendor to ask more than just the

four required CoreQ other survey questions

Metric #5: Resident

Experience/Satisfaction

CoreQ Required Questions:

All CoreQ Measures use the same 5-point Likert Scale:

Poor (1), Average (2), Good (3), Very Good (4), Excellent (5)

1. In recommending this facility to your friends and family,

how would you rate it overall?

2. Overall, how would you rate the staff?

3. How would you rate the care you receive?

4. Overall, how would you rate the food?

The Quality Metrics Application (QMA)

• Each user will have a unique login

• Can be more than one person per facility (at

least two recommended)

• For 2020 data, QMA will be live on 1/1/2020

and stay open until 1/31/2021 at 11:59 p.m.

• Facilities will enter data for each metric

• QMA will calculate data averages “behind the

scenes”

Some Final Reminders

Remember:

• The QMA is being tested by some of your peers

before it is launched in January 2020

• DHS can not use the metrics tracking

information for regulatory purposes

• However, DHS will identify any facilities that fail

to report metrics in public report

• PARTICIPATE in WEBINARS!

BIG Dates to Remember

1. QMC Webinars in December 2019 and January 2020

2. Start tracking data for 2020 on January 1, 2020

3. First reporting period ends January 31, 2021

Quality Measurement Webinars

29

Webinar #1:Introduction to

Quality Metrics

Webinar #2: All About

Quality Metric 5

Webinar #3: Quality Metrics Application

Login and Navigation

• Tuesday, 12/10,

10-11:30am

• Thursday, 12/12,

2-3:30pm

• Friday, 12/13,

10-11:30am

• Tuesday, 12/17,

10-11:30am

• Thursday, 12/19,

2-3:30pm

• Friday, 12/20,

10-11:30am

• Tuesday, 1/7/20,

10-11:30am

• Thursday, 1/9/20,

2-3:30pm

• Friday, 1/10/20,

10-11:30am

The Department will host monthly Quality Metrics

Q & A webinars in 2020 with opportunity for you to

ask questions anonymously. Stay tuned for dates!

No registration needed, however space is limited. Login information

will be sent soon via provider alerts and on the CBC webpage.

Helpful Links for Providers

30

Quality Measurement Program: https://www.oregon.gov/DHS/PROVIDERS-

PARTNERS/LICENSING/CBC/Pages/Quality-Metrics.aspx

CBC News Page (provider alerts):https://www.oregon.gov/DHS/PROVIDERS-

PARTNERS/LICENSING/CBC/Pages/news.aspx

Send questions to:QualityMetrics.Acuity@dhsohs.state.or.us

Q & A

Questions?